Using Mobile Phones to Monitor and Improve Adherence to Tuberculosis Medications In collaboration with: Central TB Division

Topics Covered What is 99DOTS Features and Benefits of 99DOTS Benefit to Patient Benefit to Field Staff Benefit to District Supervisors 99DOTS Workflow in TB-HIV collaborative intervention of ART and RNTCP department 99DOTS Dashboard Workflow Overview of ART and RNTCP Responsibilities in 99DOTS 99DOTS Video

What is 99DOTS? Strengthening DOTS monitoring through real-time adherence monitoring

Goal: to provide 99% of the benefits of DOTS at a fraction of the cost and inconvenience to patients Anti-TB drugs are wrapped in envelopes which are printed with hidden numbers behind the pills When patients dispense a dose, they reveal a hidden TOLL FREE number which they call This call gets reflected on the 99DOTS dashboard and the 99DOTS Android Mobile App immediately as a taken dose

99DOTS: Accurate Monitoring at Very Low Cost

How can the Patient data be accessed? Different ways of accessing the patient data – Web dashboard (www.99dots.org) Every center will be given their own login ID and Password to access their patients Different logins for ART center, DTC and field staff (with limited permissions) Mobile app (For Android phones) Most of the functions that you can do on the Web dashboard can be done through the mobile app SMS Alerts for Staff and Treatment Supporters to take immediate action

Calendar View of Adherence

New patient (740XXXXXX) enrolled, Yelahanka district SMS Alerts from 99DOTS Reminders to Patients Alerts to Staff [0000] Two of your patients have missed doses SMS Message: SMS Message: [0000] Please Two of your take pills Please patients have missed doses today: Raj & take pills Om Raj (979XXXXXX) & Om (812XXXXXX) Notification of new patients Analytics and Reports for Program New patient (740XXXXXX) enrolled, Yelahanka district SMS Message: [0000] Please take pills

Features of 99DOTS Calls are completely free for patients Calls can be made even when the patient has no pre paid balance or the mobile is in roaming area Any call from a registered patient number is marked as a dose taken (personal, shared, land line) Numbers are not unique, but appear in an unpredictable sequence – ensures pill-in-hand adherence When patients call, they hear “Thank you” Calls immediately show up in the dashboard as taken doses Automatic alerts and reminders to patients and supervisors for non-adherent patients Adherence records available to field staff, medical officers, district staff and all other stakeholders in the program Two of your patients have missed doses Raj (979XXXXXX) & Om (812XXXXXX) SMS Message: today: Raj & Om

Field Staff/Supervisors Benefits of 99DOTS Less travel Increased convenience Patients Focused and more efficient care Field Staff/Supervisors Easy monitoring Accurate reports Program Officers

99DOTS Workflow for TB-HIV Co-Infected Treatment

99DOTS: Workflow - Summary Patient’s sputum is sent for testing to the RNTCP center CBNAAT testing for rapid microbiological diagnosis Patient at ART Centre with symptoms of TB Cough, Fever, Night sweats, Weight loss Continuous monitoring and follow up by RNTCP staff Patient is counseled at ART Centre to take medication in the 99DOTS packaging and registered on 99Dots website Patient identified positive for TB

TB Medication Regimen Most patients undergo treatment for 6 months FDC Intensive Phase (IP): 2 months (Isoniazid, Rifampicin, Ethambutol, and Pyrazidamide) – 4FDC Continuation Phase (CP): 4 months (Isoniazid, Rifampicin, and Ethambutol) – 3FDC FDC Pills/Day based on weight band Daily regime – easy with FDC If patient takes full course, near certain-cure After 2-3 weeks: feeling better After 6 months: negligible chance of relapse/resistance 4FDC 3 FDC

Does not receive FDCs or 99DOTS FDC Drugs by Weight WEIGHT CLASS # OF PILLS # STRIPS FOR 28 DAYS < 25 kgs Does not receive FDCs or 99DOTS 30 – 39 kgs 2 pills per day 2 40 – 54 kgs 3 pills per day 3 55 – 70 kgs 4 pills per day 4 > 70 kgs 5 pills per day 5 FDCs wrapped in custom 99DOTS envelopes based on weight (diagrams to follow)

99DOTS Envelopes – Weight Band Wise 2 pills 3 pills 4 pills 5 pills

99DOTS Envelopes – Universal Each patient gets the same sleeve, regardless of weight band Counselor/pharmacist should write number of pills/day patient should take on the envelope Every day, a patient will take prescribed number of pills and reveal 1, 2, or 3 hidden phone numbers Patient should call any one they reveal that day Patient should start at pill 1 and move in sequence (1,2,3…28), completing each column, and starting from the top at each row

Patient counseling of 99DOTS Explain 99DOTS, and importance of adherence (how many pills, every day, make free call) 6 months medication Call is free, even without balance and can be done free even when roaming Patient should follow path of pills Patient should come back every 28 days when pills are finished If patient has phone, administer first dose and make first call

99DOTS Website and App Workflow NOTE: For detailed information on how to use the 99DOTS Website or the 99DOTS Mobile app to perform various tasks, see the respective guides available on the Training Materials page. https://www.99dots.org/Info

Snapshots of 99DOTS Website Dashboard

Snapshots of 99DOTS Mobile App

99DOTS Dashboard Workflow Step 1 RNTCP – District Login : Maintain Staff Details at District and TU level using the Staff Details menu in the 99DOTS Website and also configure alert frequency for the staff to receive SMS alerts Step 2 ART Center Login: – Register Patient using the Add Case menu in the 99DOTS Website Step 3 RNTCP – District Login: Assign correct TU for all new patients using the Treatment Center tab under patient details page in 99DOTS Website Step 4 RNTCP – District Login: Link TU staff to some or all patients of the TU using the Staff Details menu in the 99DOTS Website Step 5 RNTCP – District and TU Login – Monitor patients for adherence using the Calendar menu in the 99DOTS website. Add Notes/Tags after interacting with patients, and perform various patient management tasks from the patient details page.

99DOTS Dashboard Workflow STEP 1: Staff Details STEP 2: Add Patient STEP 3: Assign Patients to TU Using the District Login, add District and TU staff details. These staff will get SMS alerts for patients listed under their district and TUs based on the alert frequency configured in this step. This is mandatory and extremely important. Register Patient on 99DOTS (using ART login) – When registering patient, select the correct District to which the patient belongs. This allows the relevant district to see the patient. From the list of Patients under District, select the required patient and allocate him/her to a TU within the district. Once patients are allocated a TU, TU Staff will start receiving alerts about the patient and see them from the TU login. STEP 5: Patient Management STEP 4: Link Patients to TU Staff S Perform various on-going patient management tasks such as: Edit Patient Details, Edit Attention Required, Adding Notes and Tags, Editing Treatment Center, Marking Manual Dosage, Closing and Reopening a Case, Reports, etc. From the Staff Details menu, link patients of a particular TU to the respective TU staff. TU staff can be linked to all patients of the TU or some patients of the TU. The TU staff will get SMS alerts for the patients they have been linked in this step.

Patient monitoring by RNTCP Login to 99dots.org or 99DOTS Mobile app to see patient adherence/notes Follow up with patients with low adherence Respond to SMS alerts, and 99DOTS requests to follow up with patients DOTS+ Supervisor/RNTCP team to review adherence at regular meetings Add notes on patient behavior to log follow ups

99DOTS – Adherence scenario Patient ID Patient name 1 2 3 4 5 6 7 8 1423 Rahul K. Patient ID Patient name 1 2 3 4 5 6 7 8 1423 Rahul K. Today is the 8th day of Rahul’s treatment and he has not called in two days Rahul gets a message reminding him to take his daily dose The RNTC staff (STS, TBHVs, DPS, field staff) also gets a message alerting them that Rahul has not taken medication in 3 days [0000] Please take pills They call Rahul, and counsels him on the importance of taking drugs every day Rahul K. (740XXXXXXX) has not taken pills. Rahul takes his medication, and calls the hidden number, so his adherence can be logged

Roles and Responsibilities of ART and RNTCP staff for TB-HIV Co-Infected treatment

99DOTS TB-HIV Co-infected Treatment Responsibility Matrix Task Responsible Department Ensuring that drugs are sent to ART Centers RNTCP – District TB Office Adding Staff Details at District and TU Level in 99DOTS website and linking them to patients. These staff will get SMS when a patient is added and when the patient misses to call the toll free number RNTCP – DPS, or any other staff designated by DTO Adding relatives or other persons close to the patient, community workers, etc. who would like to be intimated by SMS on non adherence and liking them to patients. Registering Patients on 99DOTS website (selecting correct district, adding phone numbers, and assigning correct weight band) ART Center – Data Manager Assigning Patients to the correct TU under the district RNTCP - DPS, or any other staff designated by DTO Counseling Patients about 99DOTS and how to make a call after each dosage Initially by ART Center Counselors/nurses/doctors while giving medicines. Later by RNTCP staff (for example, DPS, STS, TBHVs) who is responsible for monitoring patients adherence on 99DOTS website and responding to SMS alerts

Task Responsible Department Handing over 99DOTS wrapped drugs to patients ART Center – Pharmacist Ensuring that drugs are available, maintaining inventory, and issuing refills to patients ART Center - Pharmacist Editing Patient Details, like adding additional phone numbers, updating address change ART Center – Data Manager and RNTCP - DPS, or any other staff designated by DTO Monitoring patient list for adherence RNTCP - DPS, or any other staff designated by DTO Follow up with patience once non adherence SMS is received by the linked staff/provider RNTCP – STS, TBHVs, DPS, Field workers, or any other staff designated by DTO Adding Notes and Tags, marking manual doses, closing a case, downloading reports Changing Treatment Center details, for example in the case of change of TU/District/ART Center of patient. The DOTS Plus Supervisor (DPS) or any other staff designated by the District TB Officer (DTO) is accountable for all patients in his/her district. He/she can call patients directly after going through the dashboard and/or delegate this to the relevant field staff like STS, TBHVs, field workers, etc.

99DOTS Training Video http://bit.ly/99DOTS-ENGLISH http://bit.ly/99DOTS-HINDI